Ch 17 - Heart & Neck Vessels

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?

Accentuated An accentuated S2 means that the S2 is louder than the S1. This occurs in conditions in which the aortic or pulmonic valve has a higher closing pressure. A diminished S2 means that the S2 is softer than the S1. This occurs in conditions in which the aortic or pulmonic valves have decreased mobility. Normal split S2 can be heard over the second or third left intercostal space; it is usually heard best during inspiration and disappears during expiration. Wide split S2 is an increase in the usual splitting that persists throughout the entire respiratory cycle, and widens on expiration.

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

"Do you have any pain or discomfort in your chest?" The first question the nurse asks should be broad as this will encourage the client to share more detail regarding the source of the pain. Chest pain is one of the most serious and important symptoms often signaling coronary artery disease, potentially leading to myocardial infarction. All of the other options are more specific; these questions should only be asked when the nurse needs to narrow the focus of the cardiovascular examination.

A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. What would the nurse do next?

Auscultate for pulse rate deficit. If the nurse detects an irregular rhythm, the nurse needs to auscultate for a pulse rate deficit, which may provide further evidence of atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block. The client also should be referred for further evaluation because irregular rhythms may predispose the client to decreased cardiac output, heart failure, or emboli. It would not be necessary to inspect for a lift or palpate for a thrill. These would most likely have already been completed. Listening for a ventricular gallop would occur later, when the nurse is auscultating for normal and abnormal heart sounds.

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?

Auscultate to determine the heart rate and if the rhythm is normal The nurse should focus on one sound at a time when auscultating the precordium. Start by determining the rate and rhythm. The examiner should stand at the client's right side to perform the assessment. The client should be lying in the supine positions with the head of the bed elevated at 30 degrees. The diaphragm of the stethoscope is used to listen for the high pitched should of normal heart sounds.

A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?

Cardiac cycle The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle.

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply.

Choose foods like bananas and sweet potatoes. Walk briskly 30 minutes per day. Use a low sodium seasoning to flavor food. Encouraging physical activity, decreasing dietary intake of sodium, and increasing dietary intake of potassium, such as in bananas and sweet potato, are lifestyle modifications that can promote sustaining a healthy blood pressure. Excess alcohol consumption is a modifiable lifestyle factor that can promote hypertension. Depending on gender, alcoholic beverages should be limited from one to two per day. Dairy products tend to be high in cholesterol. Clients at risk for hypertension should avoid increasing consumption of these foods.

A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?

Client has an increased chest diameter The apical impulse may not be palpable in clients with increased anteroposterior diameters. Irregular heart rate should not interfere with the ability to palpate an apical impulse. Respiratory rate does not impact the apical impulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable.

The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action?

Closure of the atrioventricular valves. The first heart sound is the result of closure of the atrioventricular valves. The second heart sound is the result of closure of the semilunar valves. Ventricular contraction is isometric when all four valves are closed during systole. Diastole occurs when the AV valves are open and the ventricles are relaxed.

A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?

Closure of the semilunar valves. Closure of the semilunar valves, which are the aortic and pulmonic valves, causes the second heart sound, S2. The closure of these valves signals the end of systole. Isometric contraction occurs when all valves are closed, which occurs just before systole, in which no sound is produced. Closure of the AV valves produces the S1 heart sound, which is the beginning of systole. Ventricular contraction is the occurrence of systole, which produces not sound but causes ejection of blood from the ventricles.

Which characteristic of the apical pulse should a nurse expect to find in the client diagnosed with left ventricular hypertrophy?

Displaced The nurse should expect to find a displaced apical pulse for a client with left ventricular hypertrophy. In ventricular hypertrophy, the apical pulse may be larger than 1 to 2 cm, displaced, more forceful, or of longer duration. Bounding apical pulse is not a characteristic of ventricular hypertrophy.

The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds?

Erb point Erb's point is auscultated at the 3rd intercostal space at the left sternal border. The aortic area is located at the second intercostal space at the right sternal border. The mitral area is located at the fifth intercostal space near the left mid-clavicular line. The pulmonic area is located at the 2nd or 3rd intercostal space at the left sternal border.

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Have the client hold his or her breath; if the rub persists, it is pericardial. Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs.

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?

Heart attacks in his father and siblings Risk of developing heart disease is increased if one or more immediate family members (parents or siblings) have had an MI, hypertension, or high cholesterol.

A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessment should focus on the signs and symptoms of what health problem?

Heart failure Edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart causing blood returning to the heart to back up in the organs and dependent areas of the body. Edema is not associated with MI, heart block, or atherosclerosis.

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

II A grade II murmur is quiet and heard immediately when auscultating the chest. A grade I murmur is very faint, heard only after the listener has "tuned in." A grade III murmur is moderately loud. A grade IV murmur is loud.

A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

Inflammation of the pericardial sac A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur.

Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report?

Inspect for dependent edema Dependent edema results from sodium and water reabsorption through the kidneys, leading to extracellular expansion. Increased frequency of nocturia results from the redistribution of fluid at night, forcing the client to get up to void more frequently. The client should only be told to lie flat for the physical examination if the client is hypovolemic and the neck veins need to be visualized. Palpation of the carotid pulse is useful for determining whether a murmur is systolic or diastolic. Thrills are formed by the turbulence of underlying murmurs and are associated with other cardiac conditions.

To assess the function of the right side of the heart, a nurse should perform which part of the heart and neck vessel assessment?

Jugular venous pulse The jugular venous pulse is important for determining the hemodynamics of the right side of the heart. The level of the jugular venous pressure reflects right atrial (central venous) pressures, and usually right ventricular diastolic filling pressure. The carotid artery pulse is a centrally located pulse on both sides of the neck that supply blood and oxygen to the neck and head. The apical pulse is located on chest in the mitral valve area and is the result of left ventricle movement during systole. Heart sounds, such as S1 and S2, are produced by the closure of the valves and are auscultated over the entire precordium.

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?

Murmur: Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium.

A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying it as which of the following?

Myocardium The myocardium is the thickest layer of the heart, and is made up of contractile cardiac muscle cells. The epicardium is the serous membrane that covers the outer surface of the heart; the endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart. The pericardium is a tough indistensible loose-fitting fibroserous sac that attaches to the great vessels and thereby surrounds the heart.

A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system?

No current medications or treatments Subjective data is data collected from the client. No current medications or treatments is information the nurse obtained from the client. Apical heart rate 70 beats per minute, no edema of extremities noted, and apical impulse palpated at 5 intercostal space on left are examples of objective data collected by the nurse upon physical examination.

A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?

Observe for a decrease in jugular venous pressure Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume, so the nurse should observe for a decrease in jugular venous pressure. Assessing the difference in the apical and radial pulses would help the nurse assess for pulse deficit. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction).

The nurse is conducting a workshop on the measurement of jugular venous pulsation. As part of instruction, the nurse tells the students to make sure that they can distinguish between the jugular venous pulsation and carotid pulse. Which of the following characteristics is typical of the carotid pulse?

Palpable The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.

A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority?

Patient C Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection.

Upon assessment of a client's pulse, a nurse notices that the amplitude of the pulse varies between beats. Which other finding should the nurse assess for in this client?

Presence of an S3 Changes in the amplitude (or strength) of a client's pulse from beat to beat is called pulsus alternans. This is usually seen in heart failure. The nurse should assess the client for the presence of an S3 and an S4, which indicate a noncompliant ventricle. Diminished heart sounds can be present in an obese client or with hypovolemia, shock, or decreased cardiac output. A pulse that changes with respirations is called a paradoxical pulse and seen in cardiac tamponade or obstructive lung disease. A split S2 does not change the amplitude of a client's pulse.

During the auscultation of a client's heart sounds, the nurse hears a fixed S2 split. What does this heart sound indicate to the nurse?

Right ventricular failure. Fixed splitting refers to wide splitting of the second heart sound that does not vary with respiration. It occurs in right ventricular failure. Wide splitting of the second heart sound occurs with a delayed closure of the pulmonic valve and is seen in pulmonic stenosis and right bundle branch block. Paradoxical or reversed splitting appears on expiration and disappears on inspiration. It is seen in left bundle branch block.

While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate?

Shortness of breath Shortness of breath, also called orthopnea, is dyspnea that occurs while the client is lying flat and improves when the client sits up. The client would not experience relief from chest pain, palpitations or edema by sitting upright. For this reason, these options are incorrect.

The nurse notes that a client's heart rate increases with inspiration and slows down with expiration. How should the nurse document this finding?

Sinus arrhythmia In sinus arrhythmia, the heart rate speeds up and slows down in a cycle, usually becoming faster with inhalation and slower with expiration. Sinus bradycardia is a regular heart rhythm that is a rate less than 60 beats per minute. In premature atrial and ventricular contractions, a beat occurs earlier than the next expected beat and is followed by a pause.

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?

Smoking increases the heart's workload and contributes to atherosclerosis. Smoking increases cardiac workload and contributes to hypertension, plaque build-up, and blood clots. It does not directly affect contractility or cardiac conduction, and it is not a component of metabolic syndrome.

The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply.

Smoking, cholesterol and blood pressure can be controlled through lifestyle choices. Age and family history are non-modifiable risk factors.

The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement?

The client may be experiencing symptoms of heart failure. With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. This does not signal CAD, a conduction problem, or adequate compensation.

After teaching a group of students about blood flow through the heart, the instructor determines that the teaching was successful when the students state that after being received by the atria, the blood goes to which of the following?

Ventricles Blood flows from the atria into the ventricles via the atrioventricular valves. The chordate tendineae are collagen fibers that anchor the AV valve flaps to the papillary muscle within the ventricles. The semilunar valves are located at the exit of each ventricle at the beginning of the great vessels. The precordium is the anterior chest area that overlies the heart and great vessels.

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply.

Walk for at least 30 minutes/day. Use relaxation techniques to manage stress. Eat foods low in sodium. Measures to reduce the risk of CHD include eating 3½ ounces equivalent of cocoa such as dark chocolate each day to help lower blood pressure; eating foods low in saturated fats, trans fatty acids, cholesterol, and sodium; participating in an active exercise program such as walking at least 30 minutes per day; limiting alcohol intake to 2 drinks per day for men and 1 drink per day for women; managing stress by reducing personal stress as much as possible, trying muscle relaxation and deep breathing.

When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following?

a narrowed vessel A swishing sound on auscultation is a bruit which is caused by turbulent blood flow through a narrowed vessel. A bruit does not indicate decreased cardiac output. Increased central venous pressure or right heart failure would be indicated by jugular venous distention.

An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible

angina Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw.

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's

apex of the heart S1 may be heard over the entire precordium but is heard best at the apex (left MCL, fifth ICS).

During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern?

decreased cardiac output Fatigue may result from compromised cardiac output. Fatigue related to decreased cardiac output is worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing throughout the day. Severe muscular exertion and an upper respiratory infection may be associated with fatigue, but not the pattern mentioned in the scenario.

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?

orthopnea A client with heart failure may have fluid in their lungs, making it difficult to breathe when lying flat (orthopnea). An increased respiratory rate is tachypnea. Sleep apnea is a condition where the client has periods of not breathing while sleeping. Pneumonia does not present as described in the question.

A client has engorged jugular veins. What should this finding suggest to the nurse?

right atrial pressure Jugular venous pressure (JVP) reflects right atrial pressure. Engorged jugular veins are seen in right or left heart failure, pulmonary hypertension, tricuspid stenosis, and pericardial compression or tamponade. The jugular veins are not used to estimate the integrity of the aorta, patency of carotid arteries, or the closure of the tricuspid valves.